Abstract
BackgroundThe underlying mechanisms of chemotherapy-induced gastrointestinal (GI) symptoms are poorly researched. This study characterised the nature, frequency, severity and treatable causes for GI symptoms prospectively in patients undergoing chemotherapy for GI malignancy.MethodsPatients receiving chemotherapy for a GI malignancy were assessed pre-chemotherapy, then monthly for 1 year using the Gastrointestinal Symptom Rating Scale, a validated patient-reported outcome measure. Patients with new, troublesome GI symptoms were offered investigations to diagnose the cause(s). Their oncologist was alerted when investigations were abnormal.ResultsA total of 241 patients, 60% male, median age 63 years (range 30–88), were enrolled; 122 patients were withdrawn, 93%, because of progressive disease or death. During the study, > 20% patients reported chronic faecal incontinence and > 10% reported moderate or severe problems with taste, dysphagia, belching, heartburn, early satiety, appetite, nausea, abdominal cramps, peri-rectal pain, rectal flatulence, borborygmi, urgency of defecation or tenesmus. Thirty percent reported continuing passage of hard stools and 30% on-going diarrhoea. Moderate or severe fatigue affected 40% participants at its peak and persisted in 15% at 1 year. Toxicity dictated change in chemotherapy for 13–29% patients/month. Common Terminology Criteria for Adverse Events underestimated gastrointestinal morbidity. Pre-chemotherapy screening identified previously undiagnosed pathology: exocrine pancreatic insufficiency (9%), vitamin B12 deficiency (12%) and thyroid dysfunction (20%). Patients often refused investigations to diagnose their chemotherapy-induced symptoms; however, for every three investigations performed, one treatable cause was diagnosed: particularly small intestinal bacterial overgrowth (54%), bile acid malabsorption (43%), previously not described after chemotherapy, and unsuspected urinary tract infection (17%).ConclusionsPatients undergoing chemotherapy for GI malignancy commonly have difficult GI symptoms requiring active management which does not occur routinely. The underlying causes for these symptoms are often treatable or curable. Randomised trials are urgently needed to show whether timely investigation and treatment of symptoms improve quality of life and survival.Trial registrationClinicalTrials.gov Identifier: NCT02121626
Highlights
In 2015, 359,960 people in the UK were newly diagnosed with cancer
We have proposed an alternative model for the development of GI symptoms (Fig. 1a, b) namely, that abnormal GI symptoms developing as a result of cancer therapies are caused primarily by disrupted GI physiological function(s)
We demonstrated that if the clinician focused on identifying which abnormal physiological processes had developed, treatable abnormalities—e.g. bile acid malabsorption, carbohydrate malabsorption, exocrine pancreatic insufficiency, small intestinal bacterial overgrowth (SIBO) and vitamin deficiency— were frequently detected
Summary
In 2015, 359,960 people in the UK were newly diagnosed with cancer. Mortality rates have fallen over the last 10 years for most cancers, for example, oesophageal cancer by 7%, bowel cancer 15% and 32% for gastric cancer [1]. That effective treatments for many forms of cancer exist, it has become increasingly important to maintain and improve quality of life after diagnosis rather than focussing solely on reducing cancer mortality. To improve or maintain quality of life often means treating the symptoms caused by the cancer or the anti-cancer therapies. To do this effectively may require the development of new services providing expert supportive care which would improve patient well-being and enhance delivery of the optimal cancer treatment, uncompromised by toxicity [2]. The underlying mechanisms of chemotherapy-induced gastrointestinal (GI) symptoms are poorly researched. This study characterised the nature, frequency, severity and treatable causes for GI symptoms prospectively in patients undergoing chemotherapy for GI malignancy
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